Hydroxychloroquine-Induced Stevens–Johnson Syndrome in the Patient with Systemic Lupus Erythematosus: A Case Report in Kurdish Region - Iraq

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that mainly affects women. Hydroxychloroquine (HCQ) and chloroquine are widely used in the treatment of many diseases, such as malaria, rheumatic arthritis, systemic lupus erythematosus, and other Rheumatic diseases. The Stevens-Johnson Syndrome (SJS) is a rare immune complex-mediated hypersensitivity disorder that is characterised as a vesiculobullous erythema multiform of the skin, mouth, eyes, and genitals. We decided to report a thirty-year-old female patient with HCQ-developed side effects of induced SJS and its appropriate management. In conclusion, the HCQ tablet does have known side effects. One of the side effects of HCQ is SJS caused by the drug; given the worldwide use of this drug in Rheumatic diseases and its increasing need, we need to be careful about its use to control and manage its side effects.


INTRODUCTION
Systemic lupus erythematosus (SLE) is one of the chronic autoimmune diseases that mainly affects women.The disease has a relapsing and remitting course.Many organs and tissues are involved, such as, the heart, the kidneys, and the brain as well as the skin, the joints, the pericardium, and the pleura. 1 Stevens-Johnson Syndrome (SJS) is a rare immune complex-mediated hypersensitivity disorder that is described as a vesiculobullous erythema multiforme of the skin, eyes, mouth, and genitals. 2Medications seem to be the most common cause of SJS and have been impli-cated in as many as 60% of cases studied. 3JS and toxic epidermal necrolysis (TEN) are severe cutaneous adverse reactions (SCARs), carrying an associated mortality from 5-40%.Known risk factors for SJS/ TEN include female gender and certain HLA genotypes. 4,5arious medications have been described to cause SJS/ TEN with strongest associations with, antiepileptics, allopurinol, sulfa-containing antibiotics, non-steroidal anti-inflammatory agents (NSAIDs), β-lactam antibiotics, quinolones, and nevirapine.

DISCUSSION
Chloroquine and its derivatives, such as HCQ, have a long history of being used as prophylactic drugs in areas plagued by malaria. 8In a study conducted by Davoudi L et al., 9 acute generalised exanthemata's pustulosis, SJS, toxic epidermal necrolysis and rashes.HCQ is a very rare cause of drug-induced SJS.This condition begins as itchy popular erythematous eruptions in the trunk and then affects the face, organs, and mucous membranes of the mouth.It also had purulent rashes on the trunk,  limbs, and face. 10In a study by Volpe et al. 11 was a patient of rheumatoid arthritis after taking HCQ developed diffuse, erythematous exfoliative rash involving trunk and limbs, which diagnosed as a drug rash with eosinophilia and systemic symptoms syndrome.In another study, after taking HCQ, the patient developed skin symptoms of SJS such as a pruritic rash over her abdomen, which described as 'targets' with a persisting exfoliating rash and eczematous patches. 12umerous studies have shown that the use of HCQ in some patients with COVID-19 may cause gastrointestinal symptoms and heart problems, [13][14][15] but so far there have been no reports that taking HCQ leads to the symptoms of SJS, which develops skin rashes in different parts of the body, especially in the oropharynx.Skin manifestations of COVID-19 included erythematous rash, urticaria, and chickenpox-like vesicles. 16

CONCLUSIONS
The HCQ tablet does have known side effects.One of the side effects of HCQ is SJS caused by the drug, and given the worldwide use of this drug in Rheumatic diseases and the increasing need for this drug, we need to be careful about its use to control and manage its side effects.
Finally, a diagnosis of SJS was made.HCQ was discontinued, then patient started on treatment by applying canula, and foley catheter (fluid replacement G/S+N/S 1*4 daily, with Ceftriaxone vial 1g BID, par acetol bottle 1*3, dexamethasone 8mg BID, Heparin 1cc BID, lactulose syrup for constipation, artificial eye drops for eye, Tel fast tab), with daily follow-up of patient with team consist of internist, Rheumatologist, and plastic.After 10 days remaining in hospital, she became better clinically and by investigation, and she discharged after three months she recovered fully, with only some sort of skin exfoliation remaining on distal forearm.

Figure 1 .
Figure 1.Multiple erythematous exfoliated patches on an erythematous base on the arm.

Figure 2 .
Figure 2. Erythematous exfoliated patches with multiple erosion on erythematous base on the distal extremities of lower limb.